Beruflich Dokumente
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ISSN 2214-9996
http://dx.doi.org/10.1016/j.aogh.2015.11.002
REVIEW
Abstract
B A C K G R O U N D The incidence of type 2 diabetes (T2D) and its economic burden have increased in
Venezuela, posing difcult challenges in a country already in great turmoil.
O B J E C T I V E S The aim of this study was to review the prevalence, causes, prevention, management,
health policies, and challenges for successful management of diabetes and its complications in
Venezuela.
M E T H O D S A comprehensive literature review spanning 1960 to 2015 was performed. Literature not
indexed also was reviewed. The weighted prevalence of diabetes and prediabetes was estimated from
published regional and subnational population-based studies. Diabetes care strategies were analyzed.
F I N D I N G S In Venezuela, the weighted prevalence of diabetes was 7.7% and prediabetes was 11.2%.
Diabetes was the fth leading cause of death (7.1%) in 2012 with the mortality rate increasing 7% per
year from 1990 to 2012. In 2012, cardiovascular disease and diabetes together were the leading cause of
disability-adjusted life years.T2D drivers are genetic, epigenetic, and lifestyle, including unhealthy dietary
patterns and physical inactivity. Obesity, insulin resistance, and metabolic syndrome are present at lower
cutoffs for body mass index, homeostatic model assessment, and visceral or ectopic fat, respectively.
Institutional programs for early detection and/or prevention of T2D have not been established. Most
patients with diabetes (w87%) are cared for in public facilities in a fragmented health system. Local
clinical practice guidelines are available, but implementation is suboptimal and supporting information is
limited.
C O N C L U S I O N S Strategies to improve diabetes care in Venezuela include enhancing resources,
reducing costs, improving education, implementing screening (using Latin America Finnish Diabetes Risk
Score), promoting diabetes care units, avoiding insulin levels as diagnostic tool, correct use of oral
glucose tolerance testing and metformin as rst-line T2D treatment, and reducing health system fragmentation. Use of the Venezuelan adaptation of the transcultural Diabetes Nutrition Algorithm for
lifestyle recommendations and the Latin American Diabetes Association guidelines for pharmacologic
interventions can assist primary care physicians in diabetes management.
K E Y W O R D S diabetes, diabetes care, management, prediabetes, Venezuela
2015 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The authors declare that they have no conicts of interest regarding the publication of this article.
From the Department of Physiology, School of Medicine, Universidad Centro-Occidental Lisandro Alvarado and Cardio-metabolic Unit 7, Barquisimeto, Venezuela (RN-M); Department of Physiology, School of Medicine, University of Panam, Panama City, Panam (RN-M); The Andes Clinic of
Cardio-Metabolic Studies, Mrida, Venezuela (JPG); Physiological Sciences Department, Universidad de Oriente, Ciudad Bolvar, Venezuela (MLM);
Cardiometabolic Unit Zulia, Universidad del Zulia, Maracaibo, Venezuela (VS); Department of Social and Preventive Medicine, School of Medicine,
Universidad Central de Venezuela, Caracas, Venezuela (AR); Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at
Mount Sinai, New York, NY (JIM). Address correspondence to R.N.-M. (nietorams@gmail.com).
INTRODUCTION
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Diabetes Federation (IDF) reported that the number of people with diabetes in the world for 2013
was 382 million, and this gure will increase by
2030, particularly in developing countries.37 The
rst studies published in Venezuela reported variable diabetes prevalence rates: 6% in 1963, 2.6% in
1972, 3.7% in 1978, and 4.4% in 1997.38 However,
the methodology of these studies was heterogeneous; for instance, in one of the studies, the diabetes prevalence rate was estimated based on
glycosuria alone.38 Moreover, data from the IDF,39
published by the Latin American Diabetes Association (ALAD),40 reported a prevalence of diabetes
in Venezuela of 10.4%. According to the IDF Atlas
of Diabetes,39 age- and sex-specic global estimates
of diabetes prevalence were based on 133 studies
from 91 countries. However, only 37 studies were
national surveys, and in those countries that did not
have their own study, data from other countries
were incorporated. The selection of the surrogate
country was based on ethnic, socioeconomic, and
other population similarities, as well as geographic
proximity. Hence, it was reported that the adjusted
prevalence rate of diabetes in Venezuela was 5.9%,
but in fact, this was actually based on 2010 information from Brazilian studies.41
Three years later, a prevalence rate for diabetes in
Venezuela of 6.6% was reported.37 This corresponded to a value obtained for Barquisimeto in
the CARMELA (Cardiovascular Risk Factor Multiple Evaluation in Latin America) study comparing
prevalence rates of diabetes and other cardiovascular
risk factors in 7 cities in Latin America.2 According
to the World Health Organization, the prevalence
of elevated fasting plasma glucose (FPG) in individuals >25 years in 2008 in Venezuela was 11.1% in
men and 10.9% women.6 However, these data are
uncertain point estimates with ranges standardized
by age and without national population studies
from 2000 to 2010.6
Prevalence rates in the literature for prediabetes
and diabetes in Venezuela are summarized in
Tables 1 and 2. The weighted prevalence of diabetes
was 7.7% and prediabetes was 11.2%. These values
should be used until results of a national study are
available. The prevalence of other cardiometabolic
risk factors (obesity, dyslipidemias, hypertension,
MetS, and physical inactivity) in Venezuela has
been reviewed.21 EVESCAM (Cardio-metabolic
Health Venezuelan Study) is the rst and currently
ongoing national population survey in Venezuela to
779
780
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State
Population
Year
Author
Men
Capital
Central
Total
Capital district
Junquito Parish
321
2006
NR
NR
6.7
De Oliveria et al.42
Vargas
Catia Parish
210
2006
NR
NR
9.5
Brajkovich et al.43
Miranda
Sucre Municipality
471
2006
NR
NR
8.0
Brajkovich et al.44
Carabobo
Valencia City
100
2008
20.0
6.3
9.0
Ruiz-Fernndez et al.45
Escobedo et al.2
Lara
Andes
Women
Mrida
Barquisimeto City
1848
2009
5.6
6.3
6.0
Palavecino Municipality
337
2006
10.4
11.4
11.0
Nieto-Martnez et al.46
Rangel Municipality
140
2006
11.8
6.7
8.6
Nieto-Martnez et al.46
Ejido Parish
272
2010
15.8
14.6
14.9
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Zulia State
3108
2005
7.8
7.4
NR
Florez et al.19
(Paramo)
Zulia
Zulia
examine the prevalence of diabetes and cardiometabolic risk factors, as well as their relationships with
lifestyle.47
Mortality and diabetes DALYs in Venezuela. Diabetes-related morbidity in Venezuela has been rising
since 1990, when the incidence was 91.7 per 100,000
inhabitants, reaching 338.6 in 1999-2001.48 This
increase signicantly affected the health system, with
>110,000 primary care consultations per year.48 The
fatality rate due to diabetes was much higher in the
population >24 years (10%) compared with those
who were younger (0.6%).48 Additionally, diabetes
was the fth leading cause of death in Venezuela,
accounting for 7.1% of global deaths in 2012.49 The
mortality rate due to diabetes rose 250% from 1990
to 2012 with a 7% increase per year (Fig. 1).38,49 The
overall incidence of diabetes deaths was similar
between sexes; however, it is higher in men before
age 75 and women after age 75 (Fig. 2).49 In 2010,
Capital
Central
Andes
State
Vargas
Population
Year
Author
Men
Women
Total
NR
NR
9.0
Brajkovich et al.43
Brajkovich et al.44
Catia Parish
210
2006
Miranda
Sucre Municipality
472
2006
NR
NR
10.0
Lara
Palavecino Municipality
337
2006
19.8
14.0
15.8
Baquisimeto City
1848
2009
NR
NR
1.0
Rangel Municipality
140
2006
23.5
15.7
18.6
Nieto-Martnez et al.46
Ejido Parish
272
2010
7.0
3.7
4.5
Nieto-Martnez et al.46
Zulia State
3108
2005
19.6
14.9
NR
Florez et al.19
Mrida
Nieto-Martnez et al.46
Escobedo et al.2
(Paramo)
Zulia
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Diabetes Care in Venezuela
40
35
35.4
33.7
33.1
30
27.5 27.3 27.5
25
24 24.4
20
15
16.2
14
16.6
17.7
19
19.8
21.1
25.4 24.7
28.5
30.0 31.1
26.6
20.8
14.6
10
5
0
Years
Figure 1. Diabetes mortality rate in Venezuela between 1990 and 2012. Data source: MPPS mortality yearbooks, 1990-2012. Adapted
from reference 49.
best sensitivity-to-specicity ratio to screen individuals of both sexes and detect those with impaired
glucose regulation who would be eligible for blood
glucose testing.58 Recently, a lower cutoff for
screening (>10 points) was proposed in a
population-based sample of 521 individuals
recruited in EVESCAM.59 Considering these
data, it has been recommended that the modied
FINDRISC for Latin America be used to dene
individuals requiring an oral glucose tolerance test
(OGTT) to diagnose prediabetes or occult T2D.21
The recommendation of validating and applying
the Latin America FINDRISC for screening has
been recently endorsed by a group of Latin
American experts (Lpez-Jaramillo P, NietoMartnez RE, Aure-Fariez G, et al. Identicacin
y manejo de la Prediabetes: perspectiva Latinoamricana. Unpublished data).
700
652
Males
600
Females
Total
619
578
500
400
300
263
219 240
200
70
100
5
51 60
34 34 34
0
25-44
45-64
65-74
75 +
Total
Age (y)
Figure 2. Diabetes mortality rates by sex and age groups in Venezuela. Data source: MPPS mortality yearbooks, 2010-2012. Adapted
from reference 49.
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782
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Insulin
T1D
T2D
100
34.8
Insulin alone
84.5
14.1
15.5
20.7
6.1
48.1
78.0
42.6
Basal insulin
Basal insulin prandial insulin
Prandial insulin alone
2.4
1.9
Premixed insulin
13.4
7.4
15.5
85.9
Metformin alone
60.0
25.3
Sulfonylurea alone
0.0
11.8
Metformin sulfonylurea
13.3
44.7
26.7
18.2
is a problem with inappropriate use of insulin sampling as a diagnostic tool, particularly after substandard OGTT testing using high-carbohydrate
breakfasts.21 This behavior is facilitated by some
private laboratories that provide the service without
a medical order, although this practice lacks any
evidence-based support or defense in clinical practice guidelines.
Improper diagnoses, such as hyperinsulinism,
may prompt incorrect or, worse, harmful treatment.
In Venezuela, there are frequent off-label uses of
metformin to reverse insulin-resistant states, to
decrease levels of plasma insulin, or to treat obese
individuals with normal glucose homeostasis. Retrospective data from 924 patients attended in 3 health
centers showed heterogeneity in the indications of
metformin in Venezuela.74 In a university hospital,
metformin was correctly used and only used in
patients with T2D.74 However, in a nonuniversity
health center, metformin was used in patients with
T2D (24%), insulin resistance (34%), obesity
(11%), impaired glucose tolerance (3%), and/or polycystic ovary syndrome (PCOS; 2%).74 Finally, in a
research university setting (pharmacology unit),
metformin was indicated in T2D (9%), insulin
resistance (68%), impaired glucose tolerance
(21%), and PCOS (2%).74 This widespread use of
metformin is fueled by ease in acquisition (not
requiring a medical prescription), relatively low price
783
784
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Causes/Drivers
Pathophysiologic peculiarities
- Most patients with diabetes (w 87%) are cared for in public facilities in a
fragmented health system.
- Underfunded and uncoordinated health services.
- Treatment programs support only a small proportion of the population
affected by and at risk for diabetes.
Management
- Low success rate: only 8% of T1D and 4.3% of T2D patients attaining
recommended targets; and only 24% having A1C values <7.0%.
- An elevated proportion of T2D insulin-naive patients were reluctant to start
insulin therapy.
- Basal plus bolus insulin in T1D and 1 or 2 OGLDs in T2D were the most
popular interventions.
- Local clinical practice guidelines are available, but implementation is
suboptimal and supporting information is limited.
- Misuse of metformin is frequent with many targeted conditions not related
with hyperglycemia.
ALAD, Latin American Diabetes Association; BMI, body mass index; CV, cardiovascular; DALY, disability-adjusted life years; DPP, Diabetes Prevention Program;
LA-FINDRISC, Latyin American Finnish Diabetes Rick Score; OGLD, with oral glucoseelowering drugs; OGTT, oral glucose tolerance test; T1D, type 1 diabetes; T2D,
type 2 diabetes; tDNA, transcultural Diabetes Nutrition Algorithm.
process of social and political transformation, affecting the health system. Despite the robust and substantive social provisions contained in a new
Constitution, drafted in mid-1999 by a constitutional assembly that had been created by popular
referendum, including a constitutional right to
health and its correlative state obligations, an
effective realization of the right to health has not
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is certainly true in Venezueladand leads to difculties in access to services, services of poor technical
quality, irrational and inefcient use of available
resources, unnecessary increases in production costs,
and lower user satisfaction.3
Costs Related to Diabetes and Its Complications. T2D represents a heavy nancial burden,
are responsible for making treatment decisions during the early stages of the disease. Therefore, the
ALAD consensus statement should be promoted
to help guide primary care physicians through a
simple decision-making process for diabetes management. Additionally, the implementation of the
tDNA algorithm adapted to Venezuela for prescribing changes in diet and physical activity is
recommended. This tool also provides information
on the proper selection of patients for bariatric
surgery.21 Furthermore, nonmedical members of the
health care team, such as nurses, community health
workers, and motivated patients, should be trained
in the skills and knowledge necessary for diabetes
care, including patient self-management.87
It is well established in Venezuela that
population-based education of people with T2D
is critical to achieve their active and effective participation in the control and treatment of their disease.89,90 Previously, the IDPMS found that
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In Venezuela, diabetes affects 7.7% of the population and is the fth leading cause of death and the
11th leading cause of DALYs, with a cost of US
$412 million in 2010. These gures depend on
genetic susceptibility to develop diabetes, nutritional
status, and sedentary habits. The association of
lower waist circumference cutoff points with metabolic abnormalities reects an association to develop
insulin resistance with visceral fat. Thus, a lower
BMI cutoff (27.5 kg/m2) has been used to increase
the power to detect clinically relevant excesses in
adiposityd tantamount to a diagnosis of obesity.
The Latin America Finnish Diabetes Risk is probably the most efcient and frequently used screening
tool to detect new cases of T2D and those individuals requiring OGTT, with a cutoff score >10
points proposed for Venezuela. In local populations,
structured lifestyle intervention in accordance with
the DPP improves cardiovascular health. Notwithstanding this, Venezuela faces a fragmented health
system caught up in a torrent of social and political
transformation. This leads to the prevailing underfunded and uncoordinated health services. Consequently, the Venezuelan diabetes prevention
programs are not structured and the treatment programs support only a small proportion of the population affected by and at risk for diabetes.
Not unexpectedly, management of diabetes in
Venezuela has shown a low success rate, with only
8% of T1D and 4.3% of T2D patients attaining
recommended targets; and overall only 24% having
A1C values <7.0%. Basal plus bolus insulin in
T1D and 1 or 2 OGLDs in T2D were the most
popular interventions. An elevated proportion of
patients with insulin-naive T2D were reluctant to
787
788
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start insulin therapy. Misuse of metformin is frequent with many targeted conditions not related
with hyperglycemia.
Strategies to improve diabetes care in Venezuela
are summarized in Table 4 and should include
increasing resources, reducing costs, improving education of health care team members and patients,
promoting diabetes care units, avoiding misuse of
serum insulin testing, OGTT, and metformin,
and reducing health system fragmentation. It is
recommended to implement the use of the Venezuelan tDNA version that provides a complete
and progressive program of physical activity, as
well as the practical implementation of the Mediterranean pyramid with menus adapted to Venezuelan
habits. In addition to the tDNA, it is recommended
that the ALAD guidelines be implemented for
pharmacologic interventions to guide primary care
physicians in the decision-making process for diabetes management.
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